One-third of American women experience have had type of pelvic health disorder by the time they're 60. And about 600,000 every year have a hysterectomy – removing the uterus to relieve troubling symptoms. Overall, an estimated 20 million people in the U.S. have had a hysterectomy.
But if you have painful periods with excessive bleeding, fibroids, endometriosis, or another pelvic health problem, you should know that there are alternatives to hysterectomy to consider.
These non-cancerous tumors are generally found in the smooth muscles of the uterus. They can cause pelvic pain, infertility, and heavy menstrual bleeding. Uterine fibroids are a common reason for hysterectomies, accounting for between 177,000 and 366,000 of the annual total.
If your fibroids aren't causing symptoms, it's reasonable to use a strategy called "watchful waiting." This means monitoring the fibroids' status with your doctor and not having surgery unless problems develop. But if you're having pain, discomfort, pressure, or other symptoms, there are several less-invasive options for treating fibroids:
- Myomectomy. This is surgery to remove the fibroids alone. It can be done with an operation through your belly, laparoscopically (entering through your navel), or via hysteroscopy (in which the doctor inserts a thin, telescope-like instrument called a hysteroscope through your vagina). A laparoscopic or hysteroscopic approach is less invasive, less expensive, and requires less recovery time. The da Vinci robotic myomectomy is another technique that offers more precision and smaller cuts than standard surgery. There's a slight chance that what was thought to be a fibroid could turn out to be a cancer called uterine sarcoma. For this reason, the FDA recommends that your doctor not cut the fibroid into small sections before removing it, a process called laparoscopic morcellation.
- Uterine artery embolization (UAE), also known as uterine fibroid embolization (UFE). This is a fairly simple, noninvasive procedure in which your doctor injects small particles into the arteries in your uterus that feed the fibroids, cutting off their blood supply. Unlike a hysterectomy, this procedure preserves the uterus. It's been used for years to help stop heavy bleeding after childbirth or surgery. Symptoms improve in 85% to 90% of patients, most of them significantly.
- Medical management. Pain due to uterine fibroids can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen. If that's not enough, hormonal treatments can help with both pain and heavy periods. These treatments include birth control pills and intrauterine devices (IUDs), as well as other drugs that work in various way to reduce or eliminate your period. These aren't permanent solutions, though. Your symptoms will likely return when you stop taking them.
Menorrhagia means heavy vaginal bleeding. In many cases, the bleeding has a known cause, like uterine fibroids (see above). But in other cases, the cause remains unknown. There's a medical definition for menorrhagia – losing more than 80 milliliters of blood in each cycle. But most doctors tend to define it by how much it affects your daily life. It can cause pain, mood swings, and disruptions in your work, sex life, and other activities.
Some options for treating menorrhagia, short of hysterectomy:
- New medications. The FDA recently approved a couple of combination hormone drugs as an alternative to surgery. Both elagolix-estradiol-norethindrone(Oriahnn) and relugolix-estradiol-norethindrone (Myfembree) can dramatically reduce heavy menstrual bleeding due to uterine fibroids.
- Other medical management. The first treatment of choice for heavy periods is medical, using either birth control pills or an (IUD) that releases a hormone called levonorgestrel. Both of these treatments reduce menstrual bleeding significantly, although women report being generally more satisfied with the IUD. If you're planning to have children in the future, drugs are probably your best options.
- Endometrial ablation. Your doctor can use several techniques to remove the lining of your uterus. You should consider these only if you're done with childbearing. New, "second-generation" methods like thermal balloon ablation, cryoablation, and radiofrequency ablation have success rates up to 80%-90%. These are all outpatient procedures, mostly done in a doctor's office. So they don't have the same complication rates and long hospital stays as a hysterectomy.
- Occasionally, doctors prescribe an NSAID during your period to help reduce blood flow from the uterine lining. These medications also help ease cramps.
Uterine prolapse happens when your uterus drops from its normal position and pushes against your vaginal walls. It can be caused by several things, but one of the most common causes is vaginal childbirth. Aging, smoking, pregnancy, and obesity are also risk factors.
Obviously, a hysterectomy will solve this problem. But there are less drastic approaches you can consider. One is a vaginal pessary , a removable device placed into your vagina to support areas where there's prolapse. There are several kinds of pessaries. Your doctor can help you decide which is best for your situation. Pessaries don't cure the prolapse but can relieve symptoms partly or completely. They're often helpful during pregnancy, holding the uterus in place before it enlarges and invades the vaginal canal.
There are also many surgical methods to treat uterine prolapse. Surgeons may use more than one technique. Sometimes, one of these surgeries will have to be combined with a hysterectomy. But for some women, it's possible to avoid this step.
The risks of placing mesh through the vagina to repair pelvic organ prolapse may outweigh its benefits, according to the FDA. But mesh may be right for some situations.
Other types of surgery include repairs of:
- Tears in the vaginal wall called paravaginal defects
- Hernias of the intestine or rectum into the vagina
- Prolapse of the bladder into the vagina
More than 6.5 million American women are thought to have endometriosis. In this condition, tissue that behaves like the lining of your uterus – the endometrium – grows in other areas of your abdominal cavity, like your ovaries, fallopian tubes, or outer surface of your uterus. Symptoms include pelvic pain, painful sex, spotting between periods, and infertility. The average woman with endometriosis has symptoms for 2-5 years before being diagnosed.
About 18% of hysterectomies in the U.S. are done due to endometriosis, and it doesn't necessarily cure the problem. As many as 13% of those who have endometriosis see it return within 3 years if their ovaries are left in place. The number climbs to 40% after 5 years. And since endometriosis often affects the young – with an average age of about 27 – a surgery that eliminates the possibility of pregnancy often isn't a good alternative.
Treatments for endometriosis depend on your needs and how serious your symptoms are. For example, you can treat pain with over-the-counter or prescription pain relievers. To treat pain and abnormal menstrual bleeding, women may be prescribed hormonal treatments such as birth control pills or drugs that reduce levels of female hormones. But these drugs aren't meant to be used when you're trying to get pregnant, and they're not a permanent fix. Going off the medication usually means the endometriosis symptoms come back.
A long-term treatment for endometriosis that's more likely to help with fertility problems is laparoscopic surgery. This procedure either removes the endometrial growths and scar tissue with surgery, or burns them away with intense heat. If surgeons can't safely destroy all the growths this way, they can take a more invasive approach called a laparotomy, which involves making a larger cut in the abdomen. This requires a much longer recovery period. But it's still less invasive than hysterectomy and offers the possibility of future pregnancy.
Chronic Pelvic Pain
Chronic (long-lasting) pelvic pain is common. Some studies show that as many as 39% of women have some kind of chronic pelvic pain. It's most common in younger women, especially those between 26 and 30.
Many things can cause pelvic pain. Along with fibroids and endometriosis, they include:
- Pelvic inflammatory disease
- Bowel issues like irritable bowel syndrome
- Bladder issues such as interstitial cystitis (an inflamed bladder)
- Issues with your muscles or bones
If you've experienced sexual abuse, you're also more likely to have chronic pelvic pain.
A hysterectomy should be considered a last resort for this condition, especially since it doesn't cure many types of pelvic pain. Work with your doctor to uncover the cause of your pain, since targeting the treatment to the cause gives you the best chance of relief. For example, if you're diagnosed with uterine fibroids or endometriosis, one of the alternative treatments discussed above might work best.
Other treatments, depending on the cause of your pain, may include:
- Stopping ovulation with hormonal methods like birth control pills or other drugs
- Relaxation exercises, biofeedback, and physical therapy
- Abdominal trigger point injections, which is medication injected into painful areas in the lower wall of your belly
- Antibiotics , if an infection like pelvic inflammatory disease is the source of the pain
- Psychological counseling
It's possible that whatever your health condition might be, a hysterectomy is the most effective and appropriate treatment. But with many alternatives available, you should discuss all your options with your doctor.